Bereaved families blast preventable deaths loophole a 'systemic scandal'

dailyrecord.co.uk:

Bereaved families have branded a loophole over coroners’ warnings on preventable deaths a “systemic scandal” and called for an independent body to make sure recommendations are implemented.After an inquest, coroners can issue Prevention of Future Death (PFD) reports to an organisation, local authority, government agency or person in a bid to stop similar losses of life – but the suggested changes are not legally enforceable.The INQUEST charity says its campaign for an overhaul has been boosted after the Independent Advisory Panel on Deaths in Custody (IAPDC) suggested the Government sets up a new body to audit, follow up and collate PFD report recommendations.Richard Caseby, whose 23-year-old son Matthew died hours after escaping over a low fence at Birmingham’s Priory Hospital Woodbourne in 2020 when he was left unattended in a courtyard, was one of the bereaved to give evidence to the panel.The inquest jury ruled Matthew’s death was contributed to by neglect by the hospital.Mr Caseby said: “The coroner at Matthew’s inquest made a clear recommendation to the Health Secretary about the height of fences in acute psychiatric units.“I still have no idea whether anything has been done to stop this from happening to another family.“The only way to fix this is for a national commissioner to ensure that coroners’ reports are followed up and their recommendations enforced.”The IAPDC report, published on Monday, found that “the preventative potential of PFD reports is not currently being fully realised, with families criticising the current system as ‘nothing more than a paper exercise’.”Both coroners and families express “deep frustration” that further deaths take place under the very circumstances they have previously warned